Chapter 16 OSullivan (Heart Disease)

Coronary Artery Disease (CAD) - Most prevalent type of heart disease Arrhythmia disturbance in electrical activity; could be BENIGN or MALIGNANT Benign arrhythmia ex. Atrial fibrillation Malignant arrhythmia ex. Ventricular Fibrillation, Ventricular Tachycardia Sinus of Valsalva where the coronary arteries originate; the coronary arteries receive most of its blood flow during diastole not systole Autoregulation greatest influence on coronary arteriolar tone; quick response in change of metabolism on local myocardial tissue; local effect not systemic Cardiac Cycle Systole and Diastole Atrial Kick last 1/3 of ventricular filling is by contraction of atrium. First 2/3 passive filling Normal Heart Sounds S1 Closure of Mitral and Tricuspid valve Systole is between S1 and s2 Diastole is between S2 and S1 Abnormal Heart Sounds S3 also known as ventricular gallop heard in early diastole; assoc. with CHF (LVF) S4 also known as atrial gallop heard in late diastole; assoc. with MI or Hypertension Neurohormonal influences on heart Beta-adrenergic receptors Sympathetic receptor of Heart; located at the sinus node within myocardium What are the effects of sympathetic stimulation of the heart? Increase Heart rate (chronotropy) and Force of contraction (Inotropy), Vasodilation of coronary arteries What neurotransmitter? Norepinephrine (Noradrenaline) What are effects of sympathetic stimulation of alpha-adrenergic receptors on peripheral blood vessels? - Vasoconstriction and Increase in Peripheral Vascular Resistance (PVR) S2- closure of aortic and pulmonic valve

Sympathomimetics drugs that mimic sympathetic Nervous system stimulation ex. Dopamine, epinephrine (commonly used in critical care; both drugs increase CO), Atropine (increase HR in px.s with bradycardia) Sympatholytics suppress Sympathetic NS Parasymphathetic stimulation Via vagus nerve, direct impact on resting HR more than Sympathetic stimulation Effects of Parasympathetic stimulation: Heart rate depression, decrease force of atrial contraction and decrease speed of conduction through A-V node Systemic BP is product of CO and PVR Factors that affect CO Venous pressure, HR and LV contractility Factors that affect PVR arteriolar tone, vasoconstriction, blood viscosity Vasomotor center CNS regulatory site for BP control; located within the medulla Baroreceptor Reflex receptor: pressure/ stretch receptors at the internal carotid(carotid sinus) and aortic arch; key role: short term regulation of BP not long term Stimulus: Increase in arterial pressure Effect: Decrease sympha stimulation, Inc. parasympha Vice versa Mean Arterial Pressure Important in critical care (ICU); goal is keep MAP >60 mmHg; MAP is the arterial pressure within large arteries over time (cardiac cycle). MAP = (SBP + (2 x DBP)) / 3 Example: 90/60 (90 + (2 x 60)) / 3 = 70 mmHg What is Cardiac Output amount of blood that leaves ventricles in 1 min. Normal value 4-6 Liters/ min Influenced by Heart rate and Stroke volume What is Stroke Volume amount of blood that is ejected with each myocardial contraction Influenced by 3 factors a. Preload the amount of blood in ventricle at end of diastole, also known as left ventricle end diastolic volume (LEVDV) b. Contractility of ventricles c. Afterload the force the LV must generate to overcome the pressure in the aorta and open the aortic valve Increase in Preload and Contractility = Increase SV Increase in Afterload = Decrease SV 55-75% - Normal percent of preload ejected as the stroke volume

What is the most widely used index of contractility? Ejection Fraction

What is Cardiac Index (CI)? In critical care settings, CI is more used than CO. CI is the relationship of CO to the body surface area expressed in meters. CI = CO/ Body Surface area Normal Value = 2.5 to 3.5 L/min/m 2

MVO2/ Myocardial oxygen demand Also known as Rate Pressure Product (RPP) or Double product Heart rate x SBP Chronotropic Incompetence Insufficient HR response to increase VO2

Abnormal Exercise Response: 1.) Failure of systolic pressure to rise, 2.) BP >200 mmhg for systolic and >110 mmhg for diastolic 3.) decrease in systolic bp of 10-15 mm Hg Paroxysmal Nocturnal dyspnea dyspnea that awakens pxs from sleep but relieved at upright position; this associated with left ventricular failure Dressler Syndrome Post MI pericarditis METs basic oxygen requirement at rest; 3.5 ml O2/kg/min Persantine Thallium Test when px cannot do exercise testing because of neuromuscular limitation, musculoskeletal problems Levine sign patient clench fist over sternum during angina Cardiogenic Shock After MI if there is not enough CO and Arterial pressure to supply organs; Treatment: Intra-aortic balloon pump (IABP) Negative Treppe Effect In a failing heart, increase in HR may cause decrease in force Ectopic beat A beat that originates from a site other than the sinus node